Skip to main content

Advertisement

SpringerLink
Log in

Leitsymptom Schwindel aus Sicht des Neurologen

Cardinal symptom vertigo from the neurologist’s perspective

  • Leitthema
  • Published:
HNO Aims and scope Submit manuscript

Zusammenfassung

Bei Patienten mit Schwindel ist die erste und klinisch wichtigste Frage, die an den Neurologen gestellt wird, ob es sich um ein zentrales oder peripheres Schwindelsyndrom handelt. Diese Unterscheidung ist in mehr als 90 % der Fälle durch die systematische Erhebung der Anamnese (Frage nach Art, Dauer, Auslösern der Schwindelbeschwerden und den Begleitsymptomen) und die körperliche Untersuchung möglich. Insbesondere bei akuten Schwindelbeschwerden hat sich hier ein 5-schrittiges Vorgehen bewährt: 1. Abdecktest mit der Frage nach einer vertikalen Divergenz („skew deviation“) als zentrales Zeichen und einer Komponente der „ocular tilt reaction“ (OTR), 2. Untersuchung mit und ohne Frenzel-Brille zur Differenzierung zwischen peripherem vestibulären Spontannystagmus und zentralem Fixationsnystagmus, 3. Untersuchung der Blickfolge, 4. Untersuchung der Blickhaltefunktion (insbesondere Blickrichtungsnystagmus entgegen der Richtung eines Spontannystagmus), 5. Kopfimpulstest mit der Frage nach einem Defizit des vestibulookulären Reflexes (VOR). In Bezug auf die Therapierbarkeit von Schwindelsyndromen sind in den letzten 10 Jahren erhebliche Fortschritte in der medikamentösen Therapie erzielt worden: Kortison bei der akuten Neuritis vestibularis, Betahistin als Hochdosis- und Langzeittherapie bei M. Menière, Carbamazepin bei Vestibularisparoxysmie sowie Aminopyridine bei Downbeat- und Upbeat-Nystagmus sowie episodischer Ataxie Typ 2.

Abstract

In most patients with vertigo, the first and clinically most important question posed to neurologists is whether it is a central or a peripheral syndrome. In more than 90 % of cases, this differentiation is made possible by systematically recording the patient history (asking about the type of vertigo, the duration, triggers and accompanying symptoms) and conducting a physical examination. Particularly in the case of acute vertigo disorders, a five-step procedure has proven useful: 1. A cover test to look for vertical divergence (skew deviation) as a central sign and component of the ocular tilt reaction (OTR); 2. Examination with and without Frenzel goggles to differentiate between peripheral vestibular spontaneous nystagmus and central fixation nystagmus; 3. Examination of smooth pursuit; 4. Examination of the gaze-holding function (particularly gaze-evoked nystagmus beating in the opposite direction to spontaneous nystagmus); 5. The head impulse test to look for a deficit in the vestibulo-ocular reflex (VOR). Considerable advances have been made in the pharmacotherapy of vertigo disorders during the last 10 years, including cortisone for the treatment of acute vestibular neuritis, betahistine as a high-dose long-term treatment for Menière’s disease, carbamazepine to treat vestibular paroxysmia and aminopyridine for down- and upbeat nystagmus and episodic ataxia type 2.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Abb. 1
Abb. 2
Abb. 3
Abb. 4
Abb. 5
Abb. 6

Literatur

  1. Brandt T, Dieterich M, Strupp M (2012) Vertigo – Leitsymptom Schwindel, 2. Aufl. Springer Medizin, Heidelberg

  2. Brandt T, Schautzer F, Hamilton D et al (2005) Vestibular loss causes hippocampal atrophy and impaired spatial memory in humans. Brain 128:2732–2741

    Article  PubMed  Google Scholar 

  3. Kirchner H, Kremmyda O, Hufner K et al (2011) Clinical, electrophysiological, and MRI findings in patients with cerebellar ataxia and a bilaterally pathological head-impulse test. Ann N Y Acad Sci 1233:127–138

    Article  PubMed  Google Scholar 

  4. Hillier SL, McDonnell M (2011) Vestibular rehabilitation for unilateral peripheral vestibular dysfunction. Cochrane Database Syst Rev 2:CD005397

    PubMed  Google Scholar 

  5. Jeong SH, Kim JS, Shin JW et al (2013) Decreased serum vitamin D in idiopathic benign paroxysmal positional vertigo. J Neurol 260(3):832–838

    Article  PubMed  CAS  Google Scholar 

  6. Brandt T, Steddin S, Daroff RB (1994) Therapy for benign paroxysmal positioning vertigo, revisited. Neurology 44:796–800

    Article  PubMed  CAS  Google Scholar 

  7. Yacovino DA, Hain TC, Gualtieri F (2009) New therapeutic maneuver for anterior canal benign paroxysmal positional vertigo. J Neurol 256(11):1851–1855

    Article  PubMed  Google Scholar 

  8. Gurkov R, Flatz W, Louza J et al (2011) In vivo visualization of endolyphatic hydrops in patients with Meniere’s disease: correlation with audiovestibular function. Eur Arch Otorhinolaryngol 268(12):1743–1748

    Article  PubMed  Google Scholar 

  9. Strupp M, Hupert D, Frenzel C et al (2008) Long-term prophylactic treatment of attacks of vertigo in Meniere’s disease – comparison of a high with a low dosage of betahistine in an open trial. Acta Otolaryngol 128(5):520–524

    Article  PubMed  CAS  Google Scholar 

  10. Strupp M, Thurtell MJ, Shaikh AG et al (2011) Pharmacotherapy of vestibular and ocular motor disorders, including nystagmus. J Neurol 258(7):1207–1222

    Article  PubMed  CAS  Google Scholar 

  11. Casani AP, Piaggi P, Cerchiai N et al (2012) Intratympanic treatment of intractable unilateral Meniere disease: gentamicin or dexamethasone? A randomized controlled trial. Otolaryngol Head Neck Surg 146(3):430–437

    Article  PubMed  Google Scholar 

  12. Pullens B, Verschuur HP, Benthem PP van (2013) Surgery for Meniere’s disease. Cochrane Database Syst Rev 2:CD005395

    PubMed  Google Scholar 

  13. Strupp M, Huppert D, Frenzel C et al (2008) Long-term prophylactic treatment of attacks of vertigo in Menière’s disease -comparison of a high with a low dosage of betahistine in an open trial. Acta Otolaryngol (Stockh) 128:620–624

    Google Scholar 

  14. Lezius F, Adrion C, Mansmann U et al (2011) High-dosage betahistine dihydrochloride between 288 and 480 mg/day in patients with severe Meniere’s disease: a case series. Eur Arch Otorhinolaryngol 268(8):1237–1240

    Article  PubMed  Google Scholar 

  15. Ihler F, Bertlich M, Sharaf K et al (2012) Betahistine exerts a dose-dependent effect on cochlear stria vascularis blood flow in Guinea pigs in vivo. PLoS One 7(6):e39086

    Article  PubMed  CAS  Google Scholar 

  16. Strupp M, Zingler VC, Arbusow V et al (2004) Methylprednisolone, valacyclovir, or the combination for vestibular neuritis. N Engl J Med 351(4):354–361

    Article  PubMed  CAS  Google Scholar 

  17. Strupp M, Arbusow V, Maag KP et al (1998) Vestibular exercises improve central vestibulospinal compensation after vestibular neuritis. Neurology 51(3):838–844

    Article  PubMed  CAS  Google Scholar 

  18. Brandt T, Dieterich M (1994) Vestibular paroxysmia: vascular compression of the eighth nerve? Lancet 343(8900):798–799

    Article  PubMed  CAS  Google Scholar 

  19. Hufner K, Barresi D, Glaser M et al (2008) Vestibular paroxysmia: diagnostic features and medical treatment. Neurology 71(13):1006–1014

    Article  PubMed  CAS  Google Scholar 

  20. Strupp M, Stuckrad-Barre S von, Brandt T, Tonn JC (2013) Teaching neuroImages: compression of the eighth cranial nerve causes vestibular paroxysmia. Neurology 80(7):e77

    Article  PubMed  Google Scholar 

  21. Cnyrim CD, Newman-Toker D, Karch C et al (2008) Bedside differentiation of vestibular neuritis from central“vestibular pseudoneuritis”. J Neurol Neurosurg Psychiatry 79(4):458–460

    Article  PubMed  CAS  Google Scholar 

  22. Lempert T, Olesen J, Furman J et al (2012) Vestibular migraine: diagnostic criteria. J Vestib Res 22(4):167–172

    PubMed  Google Scholar 

  23. Neuhauser HK (2007) Epidemiology of vertigo. Curr Opin Neurol 20(1):40–46

    Article  PubMed  Google Scholar 

  24. Strupp M, Schuler O, Krafczyk S et al (2003) Treatment of downbeat nystagmus with 3,4-diaminopyridine: a placebo-controlled study. Neurology 61(2):165–170

    Article  PubMed  CAS  Google Scholar 

  25. Claassen J, Feil K, Bardins S et al (2013) Dalfampridine in patients with downbeat nystagmus-an observational study. J Neurol: 16. April 2013 (Epub ahead of print)

  26. Strupp M, Kalla R, Claassen J et al (2011) A randomized trial of 4-aminopyridine in EA2 and related familial episodic ataxias. Neurology 77(3):269–275

    Article  PubMed  CAS  Google Scholar 

  27. Claassen J, Teufel J, Kalla R et al (2013) Effects of dalfampridine on attacks in patients with episodic ataxia type 2: an observational study. J Neurol 260(2):668–669

    Article  PubMed  Google Scholar 

  28. Schniepp R, Wuehr M, Neuhaeusser M et al (2012) 4-Aminopyridine and cerebellar gait: a retrospective case series. J Neurol 259(11):2491–2493

    Article  PubMed  Google Scholar 

  29. Brandt T, Dieterich M (1986) Phobischer Attacken-Schwankschwindel, ein neues Syndrom. Münch Med Wochenschr 128:247–250

    Google Scholar 

  30. Holmberg J, Karlberg M, Harlacher U, Magnusson M (2007) One-year follow-up of cognitive behavioral therapy for phobic postural vertigo. J Neurol 254:1189–1192

    Article  PubMed  Google Scholar 

Download references

Einhaltung ethischer Richtlinien

Interessenkonflikt. M. Strupp, C. Muth, N. Böttcher, O. Bayer, J. Teufel, K. Feil, T. Bremova, O. Kremmyda, und C.S. Fischer geben an, dass kein Interessenkonflikt besteht. Dieser Beitrag beinhaltet keine Studien an Menschen oder Tieren. Alle Personen, die über Bildmaterial oder anderweitige Angaben innerhalb des Manuskripts zu identifizieren sind, haben hierzu ihre schriftliche Einwilligung gegeben. Im Falle von nicht mündigen Patienten liegt die Einwilligung eines Erziehungsberechtigen oder des gesetzlich bestellten Betreuers vor.

Author information

Authors and Affiliations

  1. Neurologische Klinik und Deutsches Schwindelzentrum, Klinikum der Universität München, Campus Großhadern, Marchioninistr. 15, 81377, München, Deutschland

    M. Strupp, C. Muth, N. Böttcher, O. Bayer, J. Teufel, K. Feil, T. Bremova, O. Kremmyda & C.S. Fischer

Authors
  1. M. Strupp
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. C. Muth
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. N. Böttcher
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. O. Bayer
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. J. Teufel
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. K. Feil
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. T. Bremova
    View author publications

    You can also search for this author in PubMed Google Scholar

  8. O. Kremmyda
    View author publications

    You can also search for this author in PubMed Google Scholar

  9. C.S. Fischer
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to M. Strupp.

Rights and permissions

Reprints and permissions

About this article

Cite this article

Strupp, M., Muth, C., Böttcher, N. et al. Leitsymptom Schwindel aus Sicht des Neurologen. HNO 61, 762–771 (2013). https://doi.org/10.1007/s00106-013-2746-8

Download citation

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00106-013-2746-8

Schlüsselwörter

Keywords

Search

Navigation